APPLICATION FOR AFFILIATE MEMBERSHIP 2015/2016

Transcription

1 ACN /1 Milton Parade Malvern Vic 3144 (03) AFFIX PHOTOGRAPH HERE APPLICATION FOR AFFILIATE MEMBERSHIP 2015/2016 This membership category is for medical practitioners who wish to join RACMA and participate in the benefits of membership. Benefits include: Receive the RACMA journal The Quarterly Receive regular e-newsletters Employment Notices Discounts to the RACMA Annual Conference Information about Conferences & workshops Invitation to an annual networking function Instructions 1. Complete all parts of this form and sign the declaration. 2. Submit the completed application form, accompanying documentation and application fee to the College National Office. 3. Return this form and all attachments to: The Chief Executive The Royal Australasian College of Medical Administrators 10/1 Milton Parade, Malvern, Vic 3144 Please note: This application form is valid for the financial year only. Applications made on expired forms will not be accepted by the College. 1

2 Application fee: $ (incl. GST) Australian applicants $ New Zealand applicants Annual Subscription Fee: $ (incl. GST) Australian applicants $ New Zealand applicants Please also refer to the current fees webpage on RACMA website. Note: Application fees are non-refundable Send a cheque or enter credit card details below: Applicant Name:. Amount: $... MasterCard Visa Cardholder Name:... Card Number: Expiry Date:. / Signature:.. Accompanying documentation Attached Office Use Photocopy of your current medical registration (Australian or New Zealand only accepted) Photocopy of your original medical degree certificate Your Curriculum Vitae, listing details of: all positions from internship to the present date including appointment dates / organisation, location and supervisor where relevant all clinical and administrative experience including the percentage of total time allocated to each any publications. Application Fee (cheque or card details) 2

3 PART A: PERSONAL DETAILS Title: Surname:. Given names:..... Post-nominals:.. Date of birth:..... Home address:.... Home . Home telephone:. Mobile: Postal address for correspondence: Work / Home (Circle Preferred) address for correspondence: Work / Home (Circle Preferred) PART B: PROFESSIONAL DETAILS Current position:.. Employer organisation: Work address:.. Telephone:.. Fax: Employer s website: PART C: EDUCATION Qualifying medical degree: Title:.. University:. Country: Year of graduation:. Other Degrees, Diplomas or Fellowships (College and year): Note: Please attach a copy of your medical degree certificate. 3

4 PART D: REGISTRATION DETAILS Registration as a legally qualified medical practitioner Place of residence / Currency date/ Registration number:.. Please attach a copy of current certificate of registration. PART E: CLINICAL EXPERIENCE Please attach your curriculum vitae with details of each position held since graduation (including intern year). PART F: INTEREST IN MEDICAL MANAGEMENT Please tick the items you are most interested in: RACMA journal The Quarterly & regular e-newsletters Employment Notices Discounts to the RACMA Annual Conference Information about conferences & workshops Invitation to an annual networking function Other (please specify) PART G: DECLARATION I hereby apply for Affiliate membership of the Royal Australasian College of Medical Administrators. I certify that the information supplied above and in the attachments is true and correct. I will notify the College of changes to my personal or professional details and undertake to pay all fees by the due date. I authorise the College to place my details on the College (Company) Register. Signature Date 4

5 PART H: PRIVACY NOTICE (For membership application and renewal forms) Personal information (including sensitive and health information) collected in this form or in connection with your RACMA membership will be used to assess and process your application, to administer your RACMA membership and to send you information about programs, services and events that may be of interest. If you do not provide the personal information RACMA requires you to provide, RACMA may not be able to process your application or provide some or all of the benefits of RACMA membership. The information RACMA collects about you may be disclosed to your nominated referees and previous employees or placements (for the purpose of assessing your application), to training settings and to individuals and organisations that provide training related services, to persons appointed to perform support, mentoring and assessment functions. Such information may also be disclosed to AHPRA and other regulatory bodies for regulatory purposes, to bodies carrying out credentialing or quality assurance activities, to hospitals or other organisations to which you apply for employment or accreditation, to organisations seeking to source expert advice or consultancy services, to organisations seeking to identify candidates for appointments and awards, to RACMA's external service providers (for example IT contractors and event organisers) and otherwise as required or authorised by law. Your name and the jurisdiction with which you are associated will be published on RACMA's website and in RACMA publications. RACMA conducts activities in Australia, New Zealand and Hong Kong. Personal information collected in Australia about a RACMA member may be disclosed to a recipient in one of those countries. RACMA may be unable to ensure that the overseas recipient does not breach the Australian Privacy Principles in relation to such information. For further information about privacy at RACMA, including information about how to access or correct your personal information and about how to make a privacy complaint, see RACMA's privacy policy at 5

6 CONSENT AND ACKNOWLEDGMENT I,.(insert name of applicant), an applicant for membership / renewal of membership of the Royal Australian College of Medical Administrators ('RACMA'): 1. consent to RACMA collecting personal information about me from my nominated referees for the purpose of considering my application for membership; 2. consent to RACMA disclosing such information to the types of organisations described in the above Privacy Notice, for the purposes of considering my application and administering my membership of RACMA (including to a recipient in a country outside Australia, notwithstanding that RACMA may be unable to ensure that the recipient does not breach the Australian Privacy Principles in relation to the information); 3. state that any personal information about another individual (including a nominated referee, employer or emergency contact) that I have provided with this application is provided with that individual's knowledge and consent; and 4. acknowledge that I am not required to provide this consent and may revoke it at any time, but understand that if my consent is not provided or is revoked, I may not obtain any or all the benefits of RACMA membership. Signature:. Date:.. 6